Combined posterior and left-sided superior mesenteric artery-first approach to the TRIANGLE operation for pancreatic cancer

We herein present a novel combined posterior and left-sided superior mesenteric artery (SMA) first approach to facilitate the TRIANGLE operation for pancreatoduodenectomy (PD) or total pancreatectomy (TP) in pancreatic cancer. Patients who were diagnosed with resectable pancreatic ductal adenocarcinoma who underwent PD or TP using the combined posterior and left-sided SMA-first approach to the TRIANGLE operation between June 2021 and June 2024 were included in this study. General characteristics, technical details including operative techniques, short-term outcomes, and pathological results were analyzed retrospectively and compared with those from historic cohorts undergoing single SMA-first approach resections. Overall, 126 patients were analyzed (dual-approach PD-TP, n = 33; single-approach PD-TP, n = 93). The dual-approach resection yielded more lymph nodes than the single-approach (36.17 vs 26.53; <i>p</i> < 0.001). Additionally, the rate of tumor-positive resection margins, R1 (direct), was decreased. The duration of the operation was significantly longer, and blood loss was higher with the dual approach. There was no significant difference in postoperative mortality and complications between the two approaches. Utilizing the combined posterior and left-sided first approach to SMA in PD or TP with the TRIANGLE operation proved safe and effective for achieving R0 resection with favorable short-term outcomes in borderline resectable and locally advanced pancreatic cancer.